Page 1083 - Saunders Comprehensive Review For NCLEX-RN

method for assessing urine output in an infant receiving diuretic therapy is to weigh
the diapers. Comparing intake with output would not provide an accurate measure
of urine output. Measuring the amount of water added to formula is unrelated to the
amount of output. Although urinary catheter drainage is most accurate in
determining output, it is not the most appropriate method in an infant and places
the infant at risk for infection.
Test-Taking Strategy: Note the strategic words, most appropriate. Eliminate options
3 and 4 first because they are comparable or alike and will not provide an indication
of urine output. Noting the strategic words will direct you to the correct option from
the remaining options.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Cardiovascular
Health Problem: Pediatric-Specific: Congestive Heart Failure
Priority Concepts: Clinical Judgment; Perfusion
Reference: McKinney et al. (2018), p. 1084.

367. Answer: 3

Rationale: Aortic stenosis is a narrowing or stricture of the aortic valve, causing
resistance to blood flow in the left ventricle, decreased cardiac output, left
ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic
stenosis shows signs of activity intolerance, chest pain, and dizziness when standing
for long periods. Pallor may be noted but is not specific to this type of disorder
alone. Options 2 and 4 are not related to this disorder.
Test-Taking Strategy: Focus on the subject, the characteristics of aortic stenosis.
Options 2 and 4 can be eliminated first, because they are not associated with a
cardiac disorder. From the remaining options, noting the word specifically in the
question will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Cardiovascular
Health Problem: Pediatric-Specific: Congenital Cardiac Defects
Priority Concepts: Elimination; Perfusion
Reference: Hockenberry, Wilson, Rodgers (2017), p. 747.

368. Answer: 2

Rationale: The mother should be instructed that lotions and powders should not
be applied to the incision site after cardiac surgery. Lotions and powders can irritate
the surrounding skin, which could lead to skin breakdown and subsequent infection
of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care
after cardiac surgery.
Test-Taking Strategy: Note the strategic words, need for further instruction. These
words indicate a negative event query and ask you to select an option that is an

1083